CMS-10717 Part D Formulary and Benefit Administration (FA) Supplem

Program Audit Data Request
Part D Formulary and Benefit Administration (FA)
Supplemental Questionnaire

Name of Sponsoring Organization:
Enter your response here
Contract Numbers:
Enter your response here
Name and Title of Person Completing Questionnaire:
Enter your response here
Date Completed:
Select date
This questionnaire is designed to assist CMS in understanding the unique qualities of your
organization’s FA program operations.
Please upload the completed form to HPMS within 5 business days of receiving your audit
engagement letter.
We recognize that your time is valuable and appreciate your availability to provide responses to
our questions regarding the FA program operations. The responses to these questions may be
discussed during the FA audit.
1. For purposes of transition, do you utilize prior claims history for existing enrollees

having a Plan Benefit Package (PBP) change?
Select Yes or No
If yes, do not include these enrollees in Table 4: New Enrollee Record
Layout. If no, include these enrollees in Table 4: New Enrollee Record
Layout.
2. Do you have non-calendar year Employer Group Waiver Plans (EGWPs)? If yes, please
identify the contract IDs and respective PBPs with non-calendar year EGWPs.
Enter your response here
3. Which submitted claim fields (and their associated values) do you use to determine if

any enrollee is subject to long-term care requirements?
Enter your response here
4. During the review of the sample cases, who will be walking auditors through the

various screens within the applicable platforms reviewed during audit?
Select Sponsoring Organization or Delegated Entity

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Program Audit Data Request
Part D Formulary and Benefit Administration (FA)
Supplemental Questionnaire

5. If you utilize any methods (other than claims history) to ascertain new versus ongoing

therapy for enrollees, please describe. If not, enter NA.
Enter your response here

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection
of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is
10938-NEW (Expires: TBD). The CMS control number is CMS-10717. The time required to complete this information collection
is estimated to average 701 hours per response, including the time to review instructions, search existing data resources, gather the
data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance
Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Please do not send applications, claims, payments, medical records
or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not
pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be
reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact 1800-MEDICARE.

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